CASE STUDY

Posttraumatic Stress Disorder: Rape Trauma

Jocelyn Rowley, a 20-year-old single woman, was a sophomore at a midwestern university. She
had always been a good student, but her grades had fallen recently, and she was having trouble
studying. Her academic difficulties, coupled with some problems with relationships and with
sleeping, had finally led Jocelyn to see a therapist for the first time. Although she was afraid of
being alone, she had no interest in her current friends or boyfriend. She told the therapist that
when she was doing everyday things like reading a book, she sometimes was overcome by vivid
images of violent events in which she was the victim of a mugging or an assault. These
symptoms had begun rather suddenly, and together they made her afraid that she was losing her
mind.
Most of Jocelyn’s symptoms had begun about two months before she visited the university’s
counseling service. Since then, she had been having nightmares almost every night about
unfamiliar men in dark clothing trying to harm her. She was not having trouble falling asleep, but
she was trying to stay awake to avoid the nightmares. During the day, if someone walked up
behind her and tapped her unexpectedly on the shoulder, she would be extremely startled, to the
point that her friends became offended by her reactions. When she was studying, especially if
she was reading her English textbook, images of physical brutality would intrude on her thoughts
and distract her. She had a great deal of difficulty concentrating on her schoolwork. Jocelyn also
reported problems with interpersonal relationships.
In the course of the first few therapy sessions, the psychologist asked a number of questions
about Jocelyn’s life just prior to entering therapy. During these first few sessions, Jocelyn
reported that she had begun to feel more and more dissociated from herself. She would catch a
glimpse of herself in the mirror and think, “Is that me?”. After several sessions, Jocelyn
mentioned to her therapist that she had been raped by the teaching assistant in her English
literature course. The rape occurred 2 months before she entered therapy. When it became
apparent that Jocelyn had not previously reported the rape to anyone else, her therapist strongly
advised her to contact the police. She refused, citing a number of reasons.
For several days after the rape occurred, Jocelyn believed that she had been able to keep it from
affecting her everyday life. The more she tried not to think about it, however, the more times it
came to mind. She began to feel stupid and guilty for having gone to a T.A.’s house in the first
place, and because she had not been able to anticipate the rape. Unfortunately, several other
problems soon became evident. Her exaggerated startle response became more and more of a
problem because her friends were puzzled by her intense reactions to their casual, friendly
gestures. Frequent nightmares prevented her from getting any real sleep, and she was having
trouble functioning academically. She also began to withdraw from relationships with other
people, especially her boyfriend. He responded to this retreat by pressuring her sexually.
Jocelyn recalled that her high school boyfriend had occasionally pressured her into having sex
when she thought it was too risky or when she was not interested. She denied having previously
been a victim of sexual assault, although one incident she described did sound abusive to the
therapist. When she was about 13 years old, Jocelyn went to a summer music camp to play the
trombone, an instrument not usually played by a female. One day after rehearsal, the boys in her
section ganged up on her, teasing her that “girls can’t play trombones!” One boy began to
wrestle with her and, in the melee, placed a finger inside her shorts into her vagina. Jocelyn
remembered yelling at him. The boy let her go, and then all the boys ran away. Jocelyn had
never viewed that event as being assaultive until she thought about it in reference to being raped.
Treatment during this time focused primarily on giving Jocelyn an opportunity to express her
considerable anger and frustration about her situation. For example, to deal with her fear of
walking alone after dark, she was trying to find someone to walk with her. In one session, the
therapist pointed out that the intrusive images that Jocelyn now experienced while reading her
English textbook might result from the fact that she had been reading that textbook when her
attacker grabbed her from behind. This insight did not immediately diminish the frequency of her
intrusive images, however, and she remained frustrated and depressed. By this time, Jocelyn’s
nightmares had become increasingly severe. The content of her dreams was more and more
obviously rape related.
The therapist’s treatment strategy moved to a focused, cognitive-behavioral intervention that had
two main parts. The first part was to address the cognitive processes that prolong a maladaptive
view of traumatic events. Specific procedures included self-monitoring of activities, graded task
assignments (such as going out alone), and modification of maladaptive thoughts regarding the
event (such as guilt and self-blame) (Yadin & Foa, 2007). It was continued in parallel with the
second part of the therapy, which is based on prolonged exposure. In prolonged exposure, the
victim reexperiences the original trauma in a safe situation to decrease slowly the emotional
intensity associated with memory of the event. This step is based on the notion that repeated
presentation of an aversive stimulus will lead to habituation (defined as the process by which a
person’s response to the same stimulus lessens with repeated presentations).
As the end of the semester approached, Jocelyn was able to resume her studies. This was an
important sign of improvement. Therapy was terminated somewhat prematurely after 16 sessions
(twice weekly for 8 weeks) because the semester was ending, and Jocelyn was going home for
the summer. The psychologist could not convince her to continue therapy during the summer,
although she still suffered from occasional nightmares and other symptoms. She had continued
treatment with another therapist, and her symptoms had diminished slowly over time. She now
had nightmares only on rare occasions, and they were usually triggered by a specific event, such
as viewing a sexually violent movie or when someone physically restrained her in a joking
manner.
After 10 years, her social life recovered more slowly. Jocelyn experienced residual symptoms of
posttraumatic stress disorder (PTSD) intermittently for several years. She no longer met the
formal diagnostic criteria for PTSD, however, because her symptoms were not sufficiently
frequent or severe. Jocelyn still suffered from occasional nightmares if she watched a movie or a
TV show with a scene containing sexual violence. Rape scenes did not have to be overtly graphic
to cause a nightmare. In fact, scenes in which a rape was alluded to rather than depicted on
screen were just as disturbing to Jocelyn. She tried to avoid movies or TV shows with sexual
violence. This decision might be interpreted as avoiding stimuli associated with her rape trauma
(a symptom of PTSD). Her avoidance was also the product of Jocelyn’s conscious decision not
to support the segment of the entertainment industry that profits from depicting such scenes.
Other examples of lingering mild PTSD symptoms included hypervigilance and increased startle
response. Jocelyn was hypervigilant in situations that might present a threat to her own safety.
For example, when speaking with a male colleague in his office, she was often concerned about
the distance to the door and the proximity of assistance if she called for it.
The residual effects of the rape trauma could also be seen in the way that Jocelyn struggled to
control her temper, which had become volatile. Jocelyn’s relationships with men were also
affected by the lingering impact of her rape. For a period of time in her early 20s (immediately
following the rape), Jocelyn avoided intimate contact with men entirely. She referred to this time
as her “celibacy” years. Jocelyn avoided intimacy with men to sort through her own feelings
about herself, her remaining guilt surrounding her rape, and her feelings about men. Recognition
of these ongoing difficulties led Jocelyn to decide to go back into therapy with a local
psychologist. Jocelyn’s therapist used cognitive therapy to address these problems. Her goal was
to eliminate the systematic biases in thinking that were responsible for Jocelyn’s maladaptive
feelings and behavior. She treated Jocelyn’s distorted patterns of thinking and her biased
conclusions as being testable hypotheses. She used their therapy sessions as an opportunity to
identify, test, and challenge these hypotheses. Several strategies were employed. Therapy also
included some elements of anger-management training (Novaco & Taylor, 2006).
The fact that Jocelyn’s PTSD symptoms persisted for several years after the rape may seem
discouraging. Nevertheless, beyond her subtle relationship problems, the long-term impact of the
rape was not devastating. Jocelyn was able to complete school, have a successful career, regain
closeness with family and friends, and (with a little additional help in therapy) form an intimate
and lasting relationship with a loving partner. She occasionally mourns the loss of her 20s
because her relationships were so chaotic, but she also has many important plans and hopes for
the future.